Experience from a Singapore tertiary hospital with restructuring of a vascular surgery practice in response to national and institutional policies during the COVID-19 pandemic.

Singapore was one of the first countries to be affected by COVID-19, with the index patient diagnosed on January 23, 2020. For 2 weeks in February, we had the highest number of COVID-19 cases behind China. In this article, we summarize the key national and institutional policies that were implemented in response to COVID-19. We also describe in detail, with relevant data, how our vascular surgery practice has changed because of these policies and COVID-19. We show that with a segregated team model, the vascular surgery unit can still function while reducing risk of cross-contamination. We explain the various strategies adopted to reduce outpatient and inpatient volume. We provide a detailed breakdown of the type of vascular surgical cases that were performed during the COVID-19 pandemic and compare it with preceding months. We discuss our operating room and personal protective equipment protocols in managing a COVID-19 patient and share how we continue surgical training amid the pandemic. We also discuss the challenges we might face in the future as COVID-19 regresses.

The Importance of Mandatory COVID-19 Diagnostic Testing Prior to Release from Quarantine.

A 14-day quarantine is implemented in many countries in response to the coronavirus disease pandemic. Korea implemented a mandatory quarantine for those who had close contact with infected patients and those returning from abroad. The present study explored the implications of mandatory coronavirus disease 2019 testing before releasing individuals from the 14-day quarantine in Incheon, Korea. From February 11 to July 5, 2020, 19,296 people were self-quarantined, and 56 (0.3%) of them were confirmed cases of COVID-19. Twenty (35.7%) were identified through the reporting of symptoms during quarantine, and 32 (57.1%) were identified using mandatory pre-release RT-PCR tests. Among the 32, 14 (25%) individuals reported mild symptoms and 18 (32.1%) were asymptomatic. It is suggested that mandatory diagnostic testing prior to release and the symptom-based surveillance after the 14-day quarantine may help control delayed or asymptomatic COVID-19 cases.

[Occupational safety in the treatment of COVID-19 patients : Relevant laws and regulations for the treating personnel]. / Arbeitsschutz bei der Versorgung von COVID-19-Patienten : Relevante Gesetze und Regelungen für das versorgende Personal.

The intensive medical care of COVID-19 patients presents the deployed personnel with as yet unknown challenges. For example, protective equipment is now being extensively used, which was otherwise only used in selected situations. Working in such an environment is to be evaluated differently under the aspect of occupational safety than other patient care, especially as more than 1900 suspected cases of a SARS-CoV-19 occupational disease were reported among healthcare workers in Germany. Even in a pandemic, the legal requirements remain valid and personal protective equipment (PPE) has to comply with given standards. The use of FFP3 masks is required in aerosol-forming situations, such as endotracheal intubation or bronchoscopy. In contrast to surgical face masks, there is a maximum wearing time for FFPs masks. Furthermore, in a pandemic there is a basic danger of PPE shortage and recycling of face masks is under discussion. Therefore, usage of non-EU certified PPE may come into effect but this has to follow the requirements defined by European regulations. The aim of this article is to provide an overview of the currently relevant rules and regulations in Germany.

Non-viral pathogens: Identification, relevance, and prevention for xenotransplantation.

BACKGROUND: For xenotransplantation, strategies to prevent transmission of microorganisms from the source animal to the human recipient must be closely coordinated since tissues and organs are classified as non-sterile. Strategies for international cooperation and coordination of xenogeneic infection / disease surveillance and response are available. METHODS: The regulatory frameworks and criteria on microbial safety as published by World Health Organization (WHO), European Pharmacopoeia (Ph. Eur.), European Medicines Agency (EMA) as well as U.S. Department of Health and Human Services (DHHS), Food and Drug Administration (FDA) and Center for Biologics Evaluation and Research (CBER), are outlined. RESULTS: Different sources of microbial germs are considered including potential infectious agents. Monitoring of livestock and testing of xenografts is accompanied by positive and negative controls to detect and to exclude tissue specific microorganisms such as bacteria. CONCLUSIONS: The criteria of microbial status to be considered for xenotransplants are summarized.

Infection Prevention Practices in Japan, Thailand, and the United States: Results From National Surveys.

BACKGROUND: Numerous evidence-based practices for preventing device-associated infections are available, yet the extent to which these practices are regularly used in acute care hospitals across different countries has not been compared, to our knowledge. METHODS: Data from hospital surveys conducted in Japan, the United States, and Thailand in 2012, 2013, and 2014, respectively, were evaluated to determine the use of recommended practices to prevent central line-associated bloodstream infection (CLABSI), ventilator-associated pneumonia (VAP), and catheter-associated urinary tract infection (CAUTI). The outcomes were the percentage of hospitals reporting regular use (a score of 4 or 5 on a scale from 1 [never use] to 5 [always use]) of each practice across countries and identified hospital characteristics associated with the use of selected practices in each country. RESULTS: Survey response rates were 71% in Japan and the United States and 87% in Thailand. A majority of hospitals in Japan (76.6%), Thailand (63.2%), and the United States (97.8%) used maximum barrier precautions for preventing CLABSI and semirecumbent positioning to prevent VAP (66.2% for Japan, 86.7% for Thailand, and 98.7% for the United States). Nearly all hospitals (>90%) in Thailand and the United States reported monitoring CLABSI, VAP, and CAUTI rates, whereas in Japan only CLABSI rates were monitored by a majority of hospitals. Regular use of CAUTI prevention practices was variable across the 3 countries, with only a few practices adopted by >50% of hospitals. CONCLUSIONS: A majority of hospitals in Japan, Thailand, and the United States have adopted certain practices to prevent CLABSI and VAP. Opportunities for targeting prevention activities and reducing device-associated infection risk in hospitals exist across all 3 countries.

Zero Transmission of Middle East Respiratory Syndrome: Lessons Learned From Thailand.

New emerging pathogens can quickly become a global health threat in this era. A number of Middle East respiratory syndrome (MERS) outbreaks have been linked to healthcare facilities. The healthcare-associated transmission of Middle East respiratory syndrome coronavirus (MERS-CoV) has been attributed to overcrowding, delayed diagnosis, and the breakdown of infection control systems. Strict infection control precautions and a well-prepared hospital system may have contributed to no nosocomial transmission occurring during the treatment of MERS-CoV infections imported to Thailand. The recent outbreaks of MERS and previous emerging infections provide valuable lessons to be learned. Continuous vigilance and strengthening of infection control systems will shape the capacity to prevent and control MERS-CoV or new emerging disease transmission.

Infection Prevention Strategy in Hospitals in the Era of Community-Associated Methicillin-Resistant Staphylococcus aureus in the Asia-Pacific Region: A Review.

Community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) has emerged as an important cause of healthcare-associated infection. CA-MRSA clones have replaced classic hospital MRSA clones in many countries and have shown higher potential in transmission and virulence than hospital MRSA clones. In particular, the emergence of CA-MRSA in the Asia-Pacific region is concerning owing to insufficient infection control measures in the region. The old strategies for infection prevention and control of MRSA comprised adherence to standard precaution and policy of active screening of MRSA carriers and decolonization, and it has been controversial which strategy is better in terms of outcome and cost-effectiveness. Epidemiological changes in MRSA has made the development of infection prevention strategy more complicated. Based on the literature review and the questionnaire survey, we considered infection prevention strategies for healthcare settings in the Asia-Pacific region in the era of CA-MRSA.

An appraisal of the neglected tropical diseases control program in Cameroon: the case of the national program against onchocerciasis.

BACKGROUND: Onchocerciasis is a severe parasitic infestation which causes disabling skin and subcutaneous tissue changes. Current global estimates suggest that it accounts for 1135.7 disability adjusted life years (DALYs) per 100,000 population. The disease is endemic in many African countries including Cameroon, probably suggesting that the current health policies are inadequate to achieve eradication of the disease. We aimed to appraise the current Onchocerciasis control program in Cameroon in the context of existing literature. METHODS: We carried out a MEDLINE search via PubMed to source for articles on Onchocerciasis in Cameroon. RESULTS: Our appraisal of the literature suggests that Onchocerciasis poses a significant health and economic burden in Cameroon. A composite of factors contribute to the challenge of containing and eradicating Onchocerciasis in Cameroon and include: continuous transmission of the disease; non-compliance to mass drug administration; inability of health care providers (HCPs) to adequately diagnose the disease; limited access of most individuals in endemic zones to annual preventive chemotherapy and inadequate population education on simple and practical measures to prevent the disease. More robust population-based epidemiologic studies are needed to better quantify the current disease burden and consequently guide intervention strategies for complete disease eradication. CONCLUSION: Onchocerciasis is still a neglected tropical disease (NTD) in Cameroon and urgently demands a need for intensification and probably modification of some strategies in the current onchocerciasis elimination program. Control of the disease will contribute to achievement of the corresponding Sustainable Development Goals (SDGs) quota.

Towards understanding the drivers of policy change: a case study of infection control policies for multi-drug resistant tuberculosis in South Africa.

BACKGROUND: Explaining policy change is one of the central tasks of contemporary policy analysis. In this article, we examine the changes in infection control policies for multi-drug resistant tuberculosis (MDR-TB) in South Africa from the time the country made the transition to democracy in 1994, until 2015. We focus on MDR-TB infection control and refer to decentralised management as a form of infection control. Using Kingdon's theoretical framework of policy streams, we explore the temporal ordering of policy framework changes. We also consider the role of research in motivating policy changes. METHODS: Policy documents addressing MDR-TB in South Africa over the period 1994 to 2014 were extracted. Literature on MDR-TB infection control in South Africa was extracted from PubMed using key search terms. The documents were analysed to identify the changes that occurred and the factors driving them. RESULTS: During the period under study, five different policy frameworks were implemented. The policies were meant to address the overwhelming challenge of MDR-TB in South Africa, contextualised by high prevalence of HIV infection, that threatened to undermine public health programmes and the success of antiretroviral therapy rollouts. Policy changes in MDR-TB infection control were supported by research evidence and driven by the high incidence and complexity of the disease, increasing levels of dissatisfaction among patients, challenges of physical, human and financial resources in public hospitals, and the ideologies of the political leadership. Activists and people living with HIV played an important role in highlighting the importance of MDR-TB as well as exerting pressure on policymakers, while the mass media drew public attention to infection control as both a cause of and a solution to MDR-TB. CONCLUSION: The critical factors for policy change for infection control of MDR-TB in South Africa were rooted in the socioeconomic and political environment, were supported by extensive research, and can be framed using Kingdon's policy streams approach as an interplay of the problem of the disease, political forces that prevailed and alternative proposals.

Family planning and Zika virus: need for renewed and cohesive efforts to ensure availability of intrauterine contraception in Latin America and the Caribbean.

OBJECTIVES: The advantages of intrauterine contraception (IUC) are well established (highly effective, low discontinuation rate, easy to use, low cost, and suitable for immediate postpartum use), but low levels of use in many countries and declining use in others are causes for concern. Due to the ongoing Zika virus outbreak, public health officials are calling for the continued practice of safe sex and the delay of pregnancy. Our study was conducted to assess the current situation of IUC availability and provision in Latin America and to determine the role of national policies in meeting the contraceptive needs of the populations in these countries. METHODS: A survey was conducted in Latin America and the Caribbean between December 2015 and January 2016 to assess national policies with regard to IUC provision, availability and accessibility. 18 countries participated. RESULTS: All responding countries had national policies on IUC. Many in the public sector provided the intrauterine device (IUD) free of charge, but the levonorgestrel-releasing intrauterine system (LNG-IUS) was generally available in the private sector. Some countries had very restrictive policies on who was permitted to carry out IUC insertions, but most permitted a range of health professionals to do so. Immediate postpartum IUC insertion was uncommon. Some countries placed restrictions on IUC use in women who were nulliparous, young, at high risk of catching a sexually transmitted infection or who had multiple sexual partners. CONCLUSIONS: IUC is underused in Latin America. The study reveals policy level barriers that may impede access to IUC, one of the most effective, long-acting, non-hormonal, reversible contraceptive methods. Governments should consider reviewing and rethinking their policies on contraception to ensure IUC service provision among populations at high risk of unplanned pregnancy, especially those vulnerable to Zika virus.

Medicare and Medicaid Program: Conditions of Participation for Home Health Agencies. Final rule.

This final rule revises the conditions of participation (CoPs) that home health agencies (HHAs) must meet in order to participate in the Medicare and Medicaid programs. The requirements focus on the care delivered to patients by HHAs, reflect an interdisciplinary view of patient care, allow HHAs greater flexibility in meeting quality care standards, and eliminate unnecessary procedural requirements. These changes are an integral part of our overall effort to achieve broad- based, measurable improvements in the quality of care furnished through the Medicare and Medicaid programs, while at the same time eliminating unnecessary procedural burdens on providers.

Rights and duties of patients suffering from Human immunodeficiency virus (HIV) in Tunisia.

The spread of the disease of HIV has been decreased since the promotion and protection of human rights. In Tunisian law, patient infected by HIV, as every citizen, enjoys of all his rights without any discrimination, including the right to life and dignity, the right to care access, the free choice of doctor, the right to be informed and consent before any health care and specially the right to medical confidentiality. The Code of patients rights and the law no° 2007-12 of 12 February 2007 supplementing the law no° 92-71 of 27 July 1992 related to transmitted diseases ensure the protection and the respect of these rights. However, law requires a great sense of responsibility from patients and obliges them to avoid any unconscious behavior that can risk transmission of the disease. But, the application of these laws raises always many ethical problems that need reflexions.

[International Health Regulations, Ebola, and emerging infectious diseases in Latin America and the Caribbean]. / El Reglamento Sanitario Internacional, la enfermedad por el virus del Ébola y las enfermedades infecciosas emergentes en América Latina y el Caribe.

The World Health Organization's determination of the Ebola virus disease outbreak as a public health event of international concern prompted non affected countries to implement measures to prevent, detect, and manage the introduction of the virus in their territories. The outbreak provided an opportunity to assess the operational implementation of the International Health Regulations' core capacities and health systems' preparedness to handle a potential or confirmed case of Ebola virus disease. A public health framework implemented in Latin America and Caribbean countries encompassing preparatory self-assessments, in-country visits, and follow-up suggests that the region should increase efforts to consolidate and sustain progress on core capacities and health system preparedness to face public health events with national or international repercussions.

Face shields for infection control: A review.

Face shields are personal protective equipment devices that are used by many workers (e.g., medical, dental, veterinary) for protection of the facial area and associated mucous membranes (eyes, nose, mouth) from splashes, sprays, and spatter of body fluids. Face shields are generally not used alone, but in conjunction with other protective equipment and are therefore classified as adjunctive personal protective equipment. Although there are millions of potential users of face shields, guidelines for their use vary between governmental agencies and professional societies and little research is available regarding their efficacy.

Travel behavior and deferral of Dutch blood donors: consequences for donor availability.

BACKGROUND: Donors returning from areas with outbreaks of infectious diseases may donate infectious blood back home. Geographic donor deferral is an effective measure to ensure the blood safety, but donor deferral may pose a threat for the blood supply especially after holiday seasons. Insight into the travel behavior of blood donors is a first step to define appropriate deferral strategies. This study describes the travel behavior of Dutch donors, the actual deferral, and the consequences of deferral strategies on donor availability. STUDY DESIGN AND METHODS: A questionnaire designed to assess travel behavior (destination, frequency, and duration of travels) was sent to 2000 Dutch donors. The impact of travel deferral policies on donor availability was calculated, expressed as proportionate decrease in donor availability. The deferral policies considered were 1) deferral based on entire countries instead of affected regions where an infection is prevalent and 2) deferral after any travel outside Europe ("universal deferral"). RESULTS: Of the 1340 respondents, 790 (58.9%) donors traveled within Europe only, 61 (4.6%) outside Europe only, and 250 (18.7%) within and outside Europe. The deferral for entire countries and universal deferral would lead to 11.1 and 11.4% decrease in donor availability, respectively. CONCLUSION: Most Dutch donors traveled outside the Netherlands, while 23.2% traveled outside Europe. Universal deferral resulted in an additional decrease in donor availability of 0.3% compared with deferral for entire countries instead of affected regions where an infection is prevalent. Thus, the universal deferral could be considered as a simpler and safer measure.

Sharp truth: health care workers remain at risk of bloodborne infection.

BACKGROUND: In 2013, new regulations for the prevention of sharps injuries were introduced in the UK. All health care employers are required to provide the safest possible working environment by preventing or controlling the risk of sharps injuries. AIMS: To analyse data on significant occupational sharps injuries among health care workers in England, Wales and Northern Ireland before the introduction of the 2013 regulations and to assess bloodborne virus seroconversions among health care workers sustaining a blood or body fluid exposure. METHODS: Analysis of 10 years of information on percutaneous and mucocutaneous exposures to blood or other body fluids from source patients infected with a bloodborne virus, collected in England, Wales and Northern Ireland through routine surveillance of health care workers reported for the period 2002-11. RESULTS: A total of 2947 sharps injuries involving a source patient infected with a bloodborne virus were reported by health care workers. Significant sharps injuries were 67% higher in 2011 compared with 2002. Sharps injuries involving an HIV-, hepatitis B virus- or hepatitis C virus (HCV)-infected source patient increased by 107, 69 and 60%, respectively, between 2002 and 2011. During the study period, 14 health care workers acquired HCV following a sharps injury. CONCLUSIONS: Our data show that during a 10-year period prior to the introduction of new regulations in 2013, health care workers were at risk of occupationally acquired bloodborne virus infection. To prevent sharps injuries, health care service employers should adopt safety-engineered devices, institute safe systems of work and promote adherence to standard infection control procedures.

[Safety in the Microbiology laboratory]. / Seguridad en el laboratorio de Microbiología Clínica.

The normal activity in the laboratory of microbiology poses different risks - mainly biological - that can affect the health of their workers, visitors and the community. Routine health examinations (surveillance and prevention), individual awareness of self-protection, hazard identification and risk assessment of laboratory procedures, the adoption of appropriate containment measures, and the use of conscientious microbiological techniques allow laboratory to be a safe place, as records of laboratory-acquired infections and accidents show. Training and information are the cornerstones for designing a comprehensive safety plan for the laboratory. In this article, the basic concepts and the theoretical background on laboratory safety are reviewed, including the main legal regulations. Moreover, practical guidelines are presented for each laboratory to design its own safety plan according its own particular characteristics.

[Hygiene and Infection Prevention in Medical Institutions, Kindergartens and Schools - Statutory Basis, Infection Control Practice and Experiences of the Public Health Services]. / Hygiene und Infektionsprävention in medizinischen Einrichtungen und in Kindergemeinschaftseinrichtungen - Gesetzliche Grundlagen, Überwachungspraxis und Erfahrungen der Gesundheitsämter.

Infection prevention is one of the main tasks of the public health services. The "Protection against infection act" places all medical institutions and facilities for children (kindergartens and schools) under the obligation to assume responsibility and to cooperate. Duties of the institutions are described, and public health services are obliged to perform hygiene control visits.Regarding medical institutions, the guidelines of the German Commission on Hospital Hygiene and Infection Control have to be observed, and the counties were obliged to publish hygiene enactments. Subsequently, good improvements in hygiene management in medical institutions were achieved. In schools, however, severe hygienic problems (i.e. sanitary hygiene, indoor air hygiene) are detected, without any improvement - obviously due to a missing sense of responsibility in the school community. Causes for poor behaviour prevention (hand hygiene, ventilation) and missing situational prevention (i.e. cleaning) are discussed. Without reversion to the obviously needed but nearly forgotten subject school hygiene, obligatory guidelines and the assuming of responsibility, permanent improvements cannot be achieved.

[What changes were introduced by the new law concerning infectious diseases for patients with tuberculosis?]. / Jakie zmiany wprowadzila nowelizacja ustawy o chorobach zakaznych dla chorych na gruzlice?

In July 2012, the act on preventing and counteracting infections and infectious diseases in humans was amended. Many changes concerning duties of physicians looking after patients with tuberculosis were proposed. Particularly important is the requirement of written certification by patients that they were notified by the physician of the obligation to undergo antituberculous treatment. It is also essential that the national sanitary inspector be notified as to which health-care institution the patient with tuberculosis was referred to for treatment, and also about an evasion of antituberculous therapy by the patient. Many paragraphs concerning the control of infectious diseases were formulated more precisely.